A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?
Sit at or below the client's eye level during feedings.
Instruct the client to lift her chin when swallowing.
Talk with the client during her feeding.
Discourage the client from coughing during feedings.
The Correct Answer is A
Rationale:
A. Sit at or below the client's eye level during feedings: Positioning the nurse at or slightly below the client’s eye level promotes effective communication and allows close observation of swallowing. It helps the nurse monitor for signs of aspiration, coughing, or choking, which is critical in clients with dysphagia to ensure safety during meals.
B. Instruct the client to lift her chin when swallowing: Clients with dysphagia should be taught to tuck the chin slightly toward the chest, not lift it, to protect the airway and facilitate safer swallowing. Lifting the chin increases the risk of aspiration and airway compromise.
C. Talk with the client during her feeding: Talking while swallowing increases the risk of aspiration because it distracts the client and can disrupt coordinated swallowing. Silence and focused attention are recommended during feeding to ensure safe intake of food and liquids.
D. Discourage the client from coughing during feedings: Coughing is a protective reflex that clears the airway if food or liquid enters the trachea. Discouraging it could increase the risk of aspiration and choking, making it unsafe to suppress this natural defense mechanism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Rationale:
A. Wear a dosimeter film badge to measure exposure: Nurses providing care to clients with sealed radiation implants must monitor cumulative radiation exposure. Wearing a dosimeter badge ensures safety and compliance with occupational exposure limits.
B. Place a caution sign on the client's door: Posting a radiation warning sign alerts staff and visitors to the presence of a radioactive source. This precaution helps prevent accidental exposure and ensures that only authorized personnel enter the room.
C. Don a lead apron when providing care: Lead aprons reduce radiation exposure when performing close-contact procedures or bedside care. Using personal protective equipment is essential for minimizing occupational risk.
D. Discard bed linens from the client's room at the end of each day: Sealed radiation implants emit low levels of radiation and do not contaminate linens. Routine disposal of linens is unnecessary and could generate unnecessary waste. Standard laundering procedures are sufficient.
E. Instruct visitors to remain 61 cm (2 feet) away from the client: Visitors are generally instructed to maintain a greater distance, typically at least 6 feet (1.8 meters), and limit time in the room to reduce exposure. A distance of 2 feet is insufficient for safety.
Correct Answer is A
Explanation
Rationale:
A. Required immunizations: Immunizations are a key aspect of primary prevention, as they protect children from preventable diseases before exposure occurs. Including information about required vaccines at the kindergarten level helps caregivers ensure children are protected and supports community health.
B. Nutrition for children who have diabetes: Nutrition management for children with diabetes is considered secondary or tertiary prevention, as it involves managing an existing condition rather than preventing disease onset. It is not the focus for primary prevention at a general health fair.
C. Emergency disaster planning: While disaster planning is important for safety, it is not classified as primary prevention of disease. It addresses preparedness rather than preventing the initial occurrence of a health condition.
D. Screening for a pediculosis breakout: Screening is a secondary prevention activity because it involves early detection of an existing condition (lice infestation). It does not prevent the initial occurrence of disease, so it is not a primary prevention topic.
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